State Health Exchanges: The Good, The Bad, And The Glitches

Suzanne Cloud, that jazz musician we just heard, lives in Pennsylvania, one of the majority of states using the federal government's system for the new health insurance marketplace. And as we've just heard, the federal system has been plagued with problems. But what about the 16 states and District of Columbia that decided to set up their own insurance exchanges? How are they doing?

We're going to get a report card from Jocelyn Guyer. She's with the health policy consulting firm Manatt Health Solutions. They advise states, foundations and businesses on understanding federal policy when it comes to implementing the Affordable Care Act. Jocelyn Guyer, thanks for coming in.

JOCELYN GUYER: Thanks.

BLOCK: And let's talk first about some success stories. Which states seem to be doing pretty well?

GUYER: We've got a handful of states that are doing well. Kentucky is at the top of the list, but also Rhode Island, Connecticut and New York are doing well. And then, to varying degrees we're seeing Minnesota, Washington, Oregon also having relatively smooth rollouts.

BLOCK: Okay. Well, you put Kentucky at the top of that list. And let's talk about that. They've recorded 14,000 completed applicants, have about 7,000 people enrolled. What did Kentucky do right, as far as you can tell?

GUYER: Kentucky did a couple of things right. It was a little bit less ambitious about its website. It has fewer bells and whistles than the federal site in some of the other states and so they were able to really focus in on the quality and make sure that the site was running well and test it thoroughly.

The other thing is that the Kentucky site is run by an agency that includes all the key parties who have to be involved - the Medicaid agency, the folks running their marketplace and the Human Resources agency, which traditionally is responsible for some of the key tasks around figuring out who is eligible for coverage.

BLOCK: Well, let's talk about some of the states with problems, and in particular, let's talk about Maryland. It was an early adopter of the marketplace. They've been working on the system for three years but they had a whole lot of trouble when they started out last week. They had to delay the opening of the exchange, I think, for four hours and then when it did open, lots more problems. So what went wrong there?

GUYER: A couple of things. Well, the first thing that happened is a good news story, which is, like the federal exchange, Maryland had many more people seeking them out than they had expected. At the same time, Maryland, like the federal exchange, also clearly has significant technology issues that it is working through and confronting.

BLOCK: Right. And we've heard these described as glitches. It kind of reminds me of "The Princess Bride" when Inigo Montoya says, you keep using that word. I do not think it means what you think it means. These sound like more than glitches to me. These sound like fundamental problems with the site.

GUYER: I think of a glitch as you fly to Ohio and you forget your toothpaste. This is more like the airlines have lost your luggage or they've cancelled your flight. These are more serious issues than glitches and we are seeing them across the country.

BLOCK: And anything that ties this together, in terms of what is going wrong when people are not able to get onto the system or once they get there, they can't get to where they need to go?

GUYER: I think part of what happened is that people anticipated that the really tricky part of this process would be bumping up against the federal hub. And that's the system that helps states verify your income, makes sure that you're a citizen or lawfully residing. And many states were very focused on making sure the connections to that hub would go well.

In some respects, what's tripped them up has been what seems like it should have been an easier task, which is making sure people could create accounts and then get their identity established. To me, in some respects, it's a little bit like, you know, when I get my kids to finally do their homework over the weekend and then they forget to turn it in.

BLOCK: When you look overall at how enrollment has gone in this first week, would you have expected to have seen more people enrolled by now or is this about where you thought we'd be?

GUYER: Well, I would've expected to see more people enrolled, but I will say that we actually have - there's a little bit of a hidden story, which is that some states are finding very efficient ways to sign people up for the Medicaid coverage that's a key part of the Affordable Care Act. And there's states like Illinois, West Virginia and Arkansas, and what they're doing is using information they already have on hand to identify people who are eligible for Medicaid and then making it very easy for them to go ahead and sign up for that coverage.

And together, they've gotten close to enrolling over 100,000 people using those simplified enrollment strategies. And that may be the hidden story of success from this first week or two.